Thinking Outside the Doctor's Office

Some people swear by Sudafed and Tylenol to treat a cold, others by echinacea and chicken soup. And a lot of people use both together, or each at different times.

Many runners treat their injuries with the same approach. You might start with a trip to the podiatrist for your plantar fasciitis, or to an orthopedist to uncover the source of your knee pain. But increasingly, a runner with an injury—chronic or acute—will follow up with some form of alternative therapy.

This approach is called integrative or complementary medicine, because it combines mainstream medical care with alternative treatments. These treatments fall outside of what is considered conventional practice among the medical community today, yet there is at least some evidence that these treatments work. Three alternative treatments that appeal to runners, particularly those who are willing to try something new in order to avoid surgery, are Active Release Techniques, acupuncture, and prolotherapy. And, in more and more instances, the podiatrist or orthopedist refers the runner out to these therapies.

"I’m a big believer in alternative treatments," says Kevin Plancher, M.D., of Plancher Orthopaedic & Sports Medicine in New York. Plancher, an orthopedic surgeon who provides medical care to runners at the New York City Marathon, says two of the most common running injuries—plantar fasciitis (PF) and iliotibial band (ITB) syndrome—are the best candidates for alternative therapy. "I’m an orthopedic surgeon. I believe structural problems are the cause of many issues," he says. But he admits that not all problems are structural. "Both ITB syndrome and PF have a lousy track record with traditional treatments." So, for those problems, and for others that don’t respond to traditional therapy, he turns to his list of alternative treatment providers and determines the best treatment to help his patient.

A Work of ART

The new kid on the block is Active Release Techniques, a series of soft-tissue treatments that manually break up the adhesions or scar tissue in muscles, tendons and ligaments. Each ART session has two parts: diagnosis and treatment. The practitioner—a certified medical professional, usually a chiropractor or physical therapist—uses specific hands-on protocols to locate, then break up, adhesions and scar tissue that cause pain and limit motion. While the practitioner is going through his motions, he instructs the patient to do certain movements. Picture targeted massage therapy on a moving patient (though ART practitioners are quick to note that ART is not a form of massage therapy).

Michael Leahy, D.C., C.S.S.P., a chiropractor and aeronautical engineer, developed ART in the late 1980s. At the Air Force Academy, Leahy worked on feedback control systems that guided rockets and recognized the connection between the biomechanics of running and rocket science. "There are mechanisms that feed information to the nervous system about position and speed and motion, and that affects the way the muscles work," says Leahy, of Colorado Springs, CO.

When overuse—like the overuse inherent in marathon training—causes the muscles, ligaments and tendons to tighten up, break down, and hurt, ART helps get them back on track. Stuart Yoss, D.C., C.S.S.P., of Bannockburn Chiropractic and Sports Injury Center in Bannockburn, IL, explains why runners get stuck in a cycle of chronic injury. "In overuse, the muscle becomes tight and weak, which causes an increased amount of friction, pressure and tension within that muscle, which causes a state of hypoxia (lack of oxygen), which causes adhesions to form, which causes the muscle to become tight and weak. It just goes around and around." Yoss, an ART instructor as well as a practitioner, says, "That’s the essence of ART: It breaks the cumulative injury cycle."

One elite runner who broke her cycle of chronic injury through ART is Marla Runyan, who holds a 5,000m best of 14:59.20 and a marathon PR of 2:27:10. Runyan sought ART treatment from Leahy for severe plantar fasciitis. "I had the condition in my left foot for almost a solid year, and received many of the traditional treatments with no success," she says. "The scar tissue in my arch was so thick, I could not even stand up on my toes. Jogging was impossible."

She was referred to Leahy, and set out for Colorado. "Dr. Leahy took my foot and got to work. For the first time, I could feel the scar tissue and adhesions in my arch literally break apart under his fingers. It was as if he was manually changing the tissues inside my foot—something that no other treatment had been able to do."

Leahy says that, indeed, he was changing the tissues in Runyan’s foot; he was breaking apart the scar tissue. "It’s not just treating the symptom. ART actually breaks up scar tissue," he says. "We have seen before and after ultrasound images that show this."

ART is not only a treatment for injuries, but also a tool to enhance performance. Distance runners are doing the same motion over and over. If there is the slightest biomechanical flaw—and there are very few runners, elite or otherwise, who have perfect biomechanics—the repetitive motion is going to create muscle imbalance. That imbalance is the start of the injury cycle. Removing the adhesions when they are small allows runners to optimize their stride, increasing their strength and speed. "ART allows the training volume and intensity to go way up," says Leahy.

Runyan turns to ART for injury treatment and prevention, as well as performance enhancement. "Since I began running the longer distance events, I have noticed many muscle imbalances [e.g., weak hamstrings and low back], and this has caused a chronic right hip problem. ART allows me to run, prevents the condition from becoming a full-blown injury, and corrects my running mechanics and efficiency."

The Point of Pain Relief

If ART is the new kid, acupuncture is the grandfather of alternative therapy. It has been around as long as there have been runners, emerging some 5,000 years ago in China, give or take a thousand years. Acupuncturists insert needles as thin as a piece of hair into specific points on the body. The ancient description of how the needles work goes like this: These needles regulate the body’s natural energy, called qi (pronounced "chee"). Injuries cause the flow of qi to be disrupted; acupuncture restores the flow to allow the body to heal itself. "Pain is seen as an imbalance of the body’s energy state and an obstruction of the internal energy flow," says Ines

Berger, M.D., an anesthesiologist with the Medical College of Georgia in Augusta. "Acupuncture rebalances the body."

Berger blends conventional pain management techniques with the ancient Asian practice. She has treated runners with Achilles tendinitis, plantar fasciitis, hamstring pulls, and other injuries using acupuncture. "In a typical repetitive-motion injury, where the muscles get overused, micro calcifications develop in the muscles or tendons. They don’t slide smoothly over the joint lining, and the blood doesn’t flow," she explains. "When you relax the muscles, the blood flows, and the body can heal the calcifications. Acupuncture can relax the muscles so the body can heal," says Berger. She says that acupuncture also increases endorphins, those natural painkillers that runners crave.

Skepticism often makes acupuncture a treatment of last resort for runners. "If they’re skeptical and in my office, it’s because they’ve tried everything else," says Meredith Murphy, a licensed, certified acupuncturist in Bryn Mawr, PA. Murphy says that her defense against skepticism simply is successful treatment. A runner herself, Murphy can tell her own success story. After spraining her ankle, she went for one acupuncture treatment and was able to run, pain free, that same day.

Alana Watkins of Denver was a skeptic. She was training for the New York City Marathon in 2002, running about 40 miles per week, when she developed plantar fasciitis. "I tried everything: stretching, cortisone shots, orthopedic inserts, chiropractors, physical therapy—the whole nine yards," she says. After two years of pain and frustration, she was on the brink of surgery when she decided to try acupuncture. Watkins’s course of treatment began with once-a-week visits to the acupuncturist for a month, then tapered off over the next few months. Watkins felt immediate pain relief after the first treatment, and the relief lasted longer after each subsequent treatment. "After about two months—maybe five or six treatments—I was pretty much completely pain free," says Watkins. "There were several contributing factors, both physical and psychological, but my acupuncturist was the catalyst for the healing process finally being set in motion."

Dr. Berger says that the recent popularity of this all-natural technique is due, in part, to a modern problem. The doping scandal in track and field and drug use in other sports has spurred interest in natural treatments such as acupuncture. "The athletes don’t want to take any chances," she says.

Body, Heal Thyself

As with ART, prolotherapy is a method of repairing damaged soft tissue. Instead of manually working to remove scar tissue, the osteopaths and M.D.s who practice prolotherapy use injections to stimulate the body to generate healthy, stronger tissue. Doctors began using prolotherapy in its current form in the 1950s, though the concept dates back to Hippocrates.

A solution, typically dextrose (sugar water), combined with an anesthetic to dull the pain of the injection, is injected into a weak or damaged ligament or tendon. Then, the body takes over. The injection causes inflammation, swelling, and pain—it’s a trick to make the body think that a fresh injury has occurred. The body reacts to the inflammation by increasing the blood supply to the damaged area, which results, naturally, in tissue repair. "In a sense, we are turning the body’s own natural healing system back on," says Brian J. Shiple, D.O., who performs thousands of prolotherapy injections per year, and says that 80 to 90 percent of patients who receive those injections have good to excellent results.

Prolotherapy injections do not contain the anti-inflammatory steroid cortisone; in fact, prolotherapy could be considered the anti-cortisone treatment because the key to the treatment is inflammation. Currently there is no protocol for treatment; it’s extremely important to find a doctor who has exceptional knowledge of anatomy and is trained and experienced in prolotherapy. The number of injections per treatment, the number and frequency of treatments, and the amount and concentration of the solution are the doctor’s call, and all depend on the location and severity of the injury.

"We treat patients anywhere from one to six times, three to six weeks apart for most conditions," says Shiple. "Some problems may need as many as 10 treatments." Post-treatment pain starts a few hours after the injection. It takes one to three days for any swelling and pain to diminish, but can last as long as five days, and in rare cases, 10 days.

Shiple, the Division Chief of Sports Medicine and Director of the Sports Medicine Fellowship Training Program for the Crozer-Keystone Health System in Springfield, PA, says that he is gaining company in the medical community in looking outside medicine’s traditional black bag to treat injuries. "Now, we’re getting referrals for prolotherapy from surgeons.

Avoiding surgery was Kandi Blomquist’s primary goal. A triathlete from Novato, CA, Blomquist tore her left medial collateral ligament while lifting weights. She could hardly walk. Her MCL had been a trouble spot before, and she knew what her long-time orthopedist was going to recommend: no training for six weeks; or surgery, then no training during recovery from surgery. "I had worked so hard to get to this point," says Blomquist, who was six weeks away from her goal race. "The thought of losing those gains was really upsetting." Instead, she headed to the Berkeley, CA, office of Donna Alderman, D.O., for a thorough exam and her first treatment, which included 18 injections into her MCL.

Blomquist reports that she never felt any pain post-treatment, just some stiffness. She took one day of complete rest, then slowly eased back into her training. Two weeks post-treatment, she had her first really challenging workout scheduled. "After an hour at race pace on the bike, followed by an hour on the treadmill, the only place my knees didn’t ache was where the prolotherapy had been done," says Blomquist. She has completed two of her four scheduled treatments, and plans to make it to the start of her triathlon healthy and confident. "It has not been painless, but to be back running, biking and swimming this fast after a pretty major injury is almost miraculous."

Not all injuries or patients are candidates for prolotherapy. Ligament or tendon ruptures off the bone are not appropriate injuries to treat with prolotherapy. In addition, people who smoke, are allergic to procaine-type anesthetics, who have bleeding disorders that require anti-clotting medications, or who are severely immuno-compromised should avoid prolotherapy.

Some doctors try other treatments before prolotherapy, because it is a more invasive treatment. Elite runners also shy away from this therapy because it often requires the patient to take a day or two off from training. "Our usual treatment protocol is a trial of ART or physical therapy prior to performing prolotherapy," says Shiple, who has worked on runners and other athletes at the U.S. Olympic Training Center in Colorado. "Sometimes ART will take care of the problem and we can avoid the needles. Other times ART will decrease the number of injections per treatment."

No Guarantees, No Excuses

Anecdotal evidence is abundant that each of these treatments holds promise, but clinical evidence is either nonexistent or just emerging. No clinical studies prove ART’s effectiveness. Acupuncture’s value in pain relief is well documented in clinical trials, but in terms of healing injuries you have to rely on word of mouth. Prolotherapy has the most clinical backing: A randomized, double-blind study on prolotherapy by Kenneth D. Reeves, M.D., and Khatab Hassanein, Ph.D., published in the peer-reviewed Journal for Alternative Therapies in Health and Medicine in March 2000 showed significant improvements in knee osteoarthritis, reducing pain and swelling, and increasing range of motion. But prolotherapy also is the treatment with the most risks, including infection, bleeding, and nerve damage.

No matter how successful any of the treatments, none offers an excuse to avoid the strength training and stretching that will help you keep future injuries at bay. Prolotherapy may build healthy tissue, but it’s your job to strengthen that new tissue. Acupuncture may start the healing process, and ART may remove scar tissue, but the treatments alone won’t make you a better runner. Yoss says, "Any problem will recur if you don’t fix the biomechanical problems, strengthen the muscles, and keep them healthy."

Approach your injury as you do your training. Research your treatment alternatives and providers as thoroughly as you research training techniques and schedules. And, as diligently as you note your splits and race times, pay attention to how you react to treatment. "One thing that acupuncture taught me is that you need to listen to your body," says Watkins.

Catherine Kedjidjian is a freelance writer specializing in health, nutrition and fitness.

A Part of Hearst Digital Media
Runner's World participates in various affiliate marketing programs, which means we may get paid commissions on editorially chosen products purchased through our links to retailer sites.